World M.J.,Queen Elizabeth Hospital Birmingham Journal of the Royal Army Medical Corps | Year: 2013

Objectives A review of 26 years of British military renal pathology showed the commonest diagnosis to be immunoglobulin A (IgA) nephropathy affecting 115/346 (33%) of cases. It was possible to follow-up 50/115 military patients with this condition with the primary objective to determine whether initial observations enabled a confident prediction of prognosis. Additionally, unpublished observations have shown that the incidence of glomerulonephritis in an Indo-Asian British military racial group was fourfold that in the majority Caucasians although the nature of pathology (IgA vs non-IgA nephropathy) was not statistically significantly different. The present study secondarily sought to determine if prognosis of IgA nephropathy was different in this Indo- Asian military group. Finally, some conclusions concerning the traditionally restrictive policy towards applicants for military service with evidence of active nephritis were attempted. Methods An archive of military renal patients covering 1985-2011 was reviewed and clinical details of cases of IgA nephropathy were extracted and analysed. Results 95 cases (80 Caucasian, 15 Indo-Asian) were reviewed. There was no racial difference (p=0.2) in initial median estimated glomerular filtration rate (eGFR, 86 vs 83 ml/min/1.73 m2). Altogether, initial median of mean arterial pressure (MAP) was 96 mm Hg (IQR=87- 103) and median proteinuria was 485 mg/24 h (IQR=195-925). There was an inverse correlation between initial eGFR and both MAP (p=0.0008) and proteinuria (p=0.0006). In the 50 patients who were followed up, the change in eGFR with time (ΔeGFR) was calculated. 10 of the 44 Caucasians and 3/6 Indo-Asians showed significant changes in eGFR but population proportions were not significantly different (p=0.2). Altogether, 11/50 (22%) showed deteriorating eGFR despite therapeutic interventions, compared with those without deterioration; this was not due to different duration of observation (p=0.08), initial MAP (p=0.23) or initial proteinuria (p=0.07). There was no statistically significant correlation between ΔeGFR and initial MAP (p=0.6) or proteinuria (p=0.7). Conclusions The proportion of military cases of IgA nephropathy with deteriorating renal function (22%) was not different from that described in civilians, suggesting that military medical management (including operational restriction where necessary) was appropriate. Initial clinical observations, including racial group, did not permit confident prediction of prognosis thus mandating followup for all military cases. Relaxing current enlistment policy would be inadvisable given the inability to confidently predict prognosis in individual cases.
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